Healthcare Provider Details

I. General information

NPI: 1306577283
Provider Name (Legal Business Name): ZACK WALTON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2022
Last Update Date: 06/30/2022
Certification Date: 06/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 E ELLIOT RD STE 105
TEMPE AZ
85284-1790
US

IV. Provider business mailing address

1224 E MCMURRAY BLVD
CASA GRANDE AZ
85122-3616
US

V. Phone/Fax

Practice location:
  • Phone: 480-360-9170
  • Fax:
Mailing address:
  • Phone: 520-208-1092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD011431
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD011431
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: